NPIMap

Organization Active NPI

Maryville Imaging, LLC

  • Radiology Clinic/Center
  • Edwardsville, IL
National Provider Identifier
1831840180
Registry record updated Aug 4, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Radiology Clinic/CenterTaxonomy code 261QR0200X
Legal business name
MARYVILLE IMAGING, LLC
Practice address
3417 Anderson Healthcare Dr
Edwardsville, IL 62025-7784
Phone
(618) 288-4929
NPI assigned
Jan 18, 2022
Organization subpart
Yes
Parent organization
MARYVILLE IMAGING, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 4, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Brian Dale Engelke
Title
Cfo
Phone
(618) 635-4242

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Radiology Clinic/Center 261QR0200X Primary

Addresses

Primary practice location

3417 Anderson Healthcare Dr
Edwardsville, IL 62025-7784

Mailing address

6800 State Route 162
Maryville, IL 62062-8500
Phone (618) 288-4929

Other names 1

  • Goshen Imaging Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220928000618 IL Part B Supplier - Independent Diagnostic Testing Facility (Idtf) 3971763186 Practice locations: Edwardsville, IL

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory

Locations

3417 Anderson Healthcare Dr
Ste 101
Edwardsville, IL 62025
Phone (618) 288-8480

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 37

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 37

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1642464000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1659571200000",
    "number": "1831840180",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6800 STATE ROUTE 162",
            "city": "MARYVILLE",
            "state": "IL",
            "postal_code": "620628500",
            "telephone_number": "618-288-4929"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3417 ANDERSON HEALTHCARE DR",
            "city": "EDWARDSVILLE",
            "state": "IL",
            "postal_code": "620257784",
            "telephone_number": "618-288-4929"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARYVILLE IMAGING, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MARYVILLE IMAGING, LLC",
        "enumeration_date": "2022-01-18",
        "last_updated": "2022-08-04",
        "certification_date": "2022-08-04",
        "status": "A",
        "authorized_official_last_name": "ENGELKE",
        "authorized_official_first_name": "BRIAN",
        "authorized_official_middle_name": "DALE",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "618-635-4242"
    },
    "taxonomies": [
        {
            "code": "261QR0200X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Radiology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Goshen Imaging",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Goshen Imaging",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Edwardsville, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 4, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.